Subcontractor Invoice - Hammerhead Construction

HAMMERHEAD CONSTRUCTION
SUBCONTRACTORS APPLICATION FOR PAYMENT FORM
(This form must be completed. If you would like to attach your invoice and/or backup information please do so)
Subcontractor:
Contact:
Address:
Phone:
Fax:
Original contract amount:
Approved change orders:
(shown on Page 2)
New contract amount:
Work completed on base
contract:
Work completed on approved
change orders:
Stored materials: (attach
invoices and insurance
Totalifi work) completed:
Date:
Requisition #:
Project:
Address:
Job Number:
The undersigned being duly sworn, certifies that all work
has been performed in accordance with this project
contract documents and further certifies that all labor,
materials, subcontractor services, federal, state and local
taxes, social security, unemployment compensation and
workman’s compensation payments and requirements have
been paid in full and indebtedness discharge for previous
request for payment received and monies received from
this request will be used to dispose of the same.
Furthermore, in consideration of the payments received,
and upon receipt of the amount due, we hereby waive,
release and agree to hold harmless all claim of RIGHT OF
LIEN on the premises above discussed, and agree to hold
harmless and indemnify the Owner from any and all claims
made by any party claiming by, through, or under us.
Authorized Signature
Less 10% retention:
Title
Total amount due:
NOTARY
Less previous payments:
State of _________, County of ______________
SWORN TO AND SUBSCRIBED BEFORE ME THIS
Less back-charges:
Curren payment due:
__________ DAY OF ___________________, 20 ____
Notary Public: __________________________________
My Commission Expires on:
HAMMERHEAD CONSTRUCTION
SUBCONTRACTORS APPLICATION FOR PAYMENT FORM
Page 2 of 2
Subcontractor:
Date:
Project:
Project Number:
SUBCONTRACTOR CHANGE ORDER SUMMARY
(Attach back-up forms and/or tickets)
Change order #:
Date:
Approved by:
Description
Amount:
.00
.00
.00
.00
.00
Approved Change Order Total:
INTERNAL USE ONLY
PENDING CHANGES, BACKCHARGES
OR ADJUSTMENTS
JOB NO. _____________________
CODE: _______________________
APPR. AMOUNT: ______________
APPR. PM: ___________________
APPR. MGT: __________________
ENTERED DATE: _____________
.00